Inguinal HerniaLaparoscopic repairSakib MotalibUniversity of Kentucky College of Medicine, M1

Inguinal Hernia Repair About the pathology Patient Symptoms Laparoscopic Treatment Procedure

Types of the Procedure: TEP vs. TAPP Steps for the repair

Post-Operative Care Benefits of Laparoscopy vs. Open Surgery Acknowledgements Questions

About Inguinal Hernia’s The inguinal region has anatomical and

clinical significance Inguinal canal components:

Males = spermatic cord Females = Round ligament

Formation of the hernia involves protrusion of peritoneum through a defect, forming a sac.

Two types of hernia’s for inguinal region: direct and indirect

Direct Inguinal Hernia

Hernia protruding through a weak point in the fascia medial to epigastric vessels

Structures interacted with: hernia sac Hesselbach’s triangle

Indirect Inguinal Hernia

hernia protrudes thru the inguinal ring, lateral to epigastric vessels

Structures interacted with: spermatic cord vas deferens testicular arteries

Causes of Inguinal Hernia Increased pressure within

abdomen: Severe coughing Straining during heavy

lifting Straining during constipation Obesity Pregnancy

Aging Genetic predisposition

Pre-existing weak spot

Patient Symptoms Mass/bulge in the

groin A burning sensation

in the groin

Strangulated hernia: Sudden pain,

nausea, vomiting

Laparoscopic treatment Position of patient:

Trendelenburg

Surgeon positions: Surgeon on opposite

side of hernia Camera operator

opposite side of surgeon

Monitors at feet of patient

Laparoscopic treatment Trocar: 10 mm trocar for

camera, 5 mm for operating devices

Camera: 30 degree laparoscope

Operating devices:1. Grasper2. Fine dissector3. Suction-irrigation device4. Curved dissector5. Finger dissector

TAPP vs. TEP TAPP

trans-abdominal pre-perotenial repair

Pneumoperitoneum is created by surgeon

Ports placed bilaterally, to either side of the camera

TAPP vs. TEP TEP

Total extraperitoneal repair

Extraperitoneal space is created by surgeon Using balloons

Ports placed below camera port, along midline

Laparoscopic Procedure TAPP

1. Make a small incision just above the umbilicus.

2. Lift up abdominal wall and gently insert Veress needle

3. Connect CO2 tube to needle4. Switch off gas when desired

pneumoperitoneum is created and remove the Veress needle

Laparoscopic Procedure TEPP:

1. 10 mm skin incision and retract to expose linea-alba (0:21)

2. small incision is made on the anterior rectus sheath on affected side (0:30)

3. Start blunt dissection to create a tunnel (1:00)

Laparoscopic Procedure4. Dissection balloon

advanced down into the pubic tubercle (1:20)

5. Balloon is hand pumped with guide of camera. (1:44)

6. Dissection balloon removed and replaced with structural balloon (3:36)

Anatomy Review

Laparoscopic Procedure

7. Insert ports, and inflate extraperitoneal space with CO2 (5:20)

8. Bluntly disect away pro-perotineal fat, identifying key organs:

• Cooper’s ligament• Epigastric vessels

(8:08)

• Spermatic cord (11:25)

Anatomy Review

Laparoscopic Procedure

7. Bluntly disect away pro-perotineal fat, identifying key organs:

• Cooper’s ligament• Epigastric vessels

(8:08)

• Spermatic cord (11:25)

Laparoscopic Procedure9. Continued dissection

After further dissection, hernia clearly identified – Indirect hernia (17:55)

Spermatic cord teased away from hernia sac (16:00)

Grab edge of peritoneal sac and drag away from defect and key structures

Laparoscopic Procedure10. Second hernia on

opposite side identified – Direct hernia

• Identify the hernia sac and dissect (28:35)

11. Pull down on plane of attachment, cleaning off fat on the abdominal wall so it does not get in the way of the mesh (32:00)

Laparoscopic Procedure

11. Put in the mesh that will cover the defect (54:00)

• polypropylene mesh• Mesh is curved,

with label M• Positioning of mesh

is significant• Tack mesh in place

or no fixation

Laparoscopic Procedure

12. Start suctioning out the CO2 in the peritoneum (1:12:00)

Push down on the mesh with suction

13. Remove ports, close the patient (close fascial layers, then superficial layers)

Dangers/Areas to be Avoided Triangle of doom

vas deferens medially

gonadal vessels laterally

peritoneum inferiorly

Inside the triangle are the iliac artery and vein

Dangers/Areas to be Avoided Triangle of pain

Contains cutaneous nerves neuralgia

Major arteries and spermatic vessels Epigastric vessels Specific example:

tension on vas deferens

Post-Operative Care

A prescription for pain medication is given to you upon discharge

Light diet the first 24 hours after surgery resume regular (light) daily activities

beginning the next day Refrain from any heavy lifting or straining until

approved by your doctor. Follow up appointment with doctor 2-3 weeks

after procedure.

Advantages/Disadvantages Advantages

less tissue dissection and disruption of tissue planes

smaller incisions just for the trocars Less pain postoperatively earlier return to normal activities for the

patient Disadvantages

Learning curve for the procedure

Acknowledgements James Hoskins, Director of MIS Training

Center Dr. John Roth, Director of Minimally

Invasive Surgery

Sources http://www.websurg.com/ref/ot-ot02en195_e

n.html http

://cme.medscape.com/viewarticle/420354_5 http://

www.webmd.com/digestive-disorders/tc/inguinal-hernia-symptoms

http://www.centralcarolinasurgery.com/forms/JAN/postop%20inguinal%20hernia%2001092009.pdf

Times listed for the procedure : based on Laproscopic inguinal hernia repair DVD; instructors: Dr. Scott Roth [S2]

Questions?